NCC242418_FRO Submitted_20240812

o�GOUN;Y.,yo�� APPLICATION FOR PERMIT FOR A File#
y LAND DISTURBING ACTIVITY
z 'a r' Under the conditions set forth by LD Fee Review Fee
3 The New Hanover County
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Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
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Engineering Department
Applicant or Applicant's Agent: Tim Clark - McKim & Creed, Inc.
Mailing Address: 243 North Front St. Telephone Number: 910-343-1048 Fax Number:910-251-8282
Wilmington, NC 28409 Email Address: tclark@mckimcreed. com
Total Acres of Land Disturbanc:'312 Purpose of Development: Convenience Store
Description of Land Disturbance: Generally the limits of the building, parking, and stormwater pond
Address of Land Disturbance 6401 Carolina Beach Rd Latitude: 34°10'63.86°N Longitude:-77°89'89.41"W
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s) of record: Person or firm(s)financially responsible for the
S D Stefanovich, Manager land disturbing activity. If not a North Carolina
resident,you MUST have a N.C.agent.(List Below)
Name: Beacon Family Properties, LLC Name: Sheetz, Inc. (Brian Downs)
Address: 6401 Carolina Beach Rd Address: 5700 Sixlli Ave 2626 Glenwood Ave., Suite 550
City/State: Wilmington, NC 28412 City/State:- Altoona, PA Raleigh, NC
Zip Code: 28412 Zip Code:_ 16602 27608
Telephone Number: 910-990-0914 Telephone Number: 919-2 6 4-8 5 9 3
[e-mail]_
Email: taxNumber Email:bdowns@sheet z .corn FaxNumber:
Location of deed(s)or instrument(s): County: New Hanover Book: 5685 page: 2 8 8 8-2 8 91
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director,partner, attorney-in-
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in the information provided herein.
Date: 1 15-gs0oZ3 Na Stev i Augustine Title Vice- President
Signature
I 1-\t,kcew Pcriol a a Notary P blic of the County of of r State of
�r: 1 ��r��u�' hereby certify that r,__ i('S1 P �v UJ•�t appeared personally before me this day and
being duly sworn acknowledged that the ab ve form was executed byhim.
Witness m hand and nottary s I,thi 5 day of c--SP 'efAr 20 �3 .
Notary 10.LJ' & 1 1 My commission expires ri 19..Jdari .
SEAL Commonwealth of Pennsylvania-Notary Seat
Andrew J.Podolak,Notary Public
Blair County
My commission expires July 19.2027
Commission number 1435770
Permission to Enter on Land Merrtper,Pennsyiva escalation of Notaries
I certify that I am authorized t rant and do in f'et grant pe sion to the Erosion Control Inspector and his agents to enter on
the land in question in C ermit a tcation.
9,-2 / , z ._.
Application Sign ture and Date S Stefanovich)
L SE COMPLETE ALL PORTIONS OF APPLICATION